THE NEW INDIA ASSURANCE COMPANY LIMITED Regd. Office: New India Building, 87, Mahatma Gandhi Road, Fort, Mumbai-400001 Mobile Handsets Insurance Claim Form Please note: - The issue of this claim form is not to be taken as an admission of liability. All columns need to be filled up in detail in all respect. Note: (*) and (*#) mark field implies mandatory fields, need to be filled in detail compulsorily or else the document shall be treated as incomplete. In case of incomplete document/details claim will be void. DETAILS OF THE INSURED/BENEFICIARY M/s. NSI Infinium Global Limited *Store Name: Store Location Date of Purchase *Name of Customer/Purchaser: DD/MM/YY (please write complete name including father/ mother/ spouse name, etc as applicable) *Address Line 1: *Address of Customer/Purchaser: (Note - Provide your reachable or present address on which any *Address Line 2: correspondence if required, can be sent) *City *Pin code: *State: CONTACT DETAILS OF CLAIMANT/BENEFICIARY Landline No: STD code Any other relevant information: *#Currently in use reachable 10 digit Mobile Contact no: Alternative contact no: Email Id: *# - Provide your currently in use reachable 10 digit Mobile contact no. which will be used for all your claim & information related communication purpose. EQUIPMENT DETAILS: *Make: *Model: DD/MM/YYYY *Purchase Date: *Purchase Invoice No: *IMEI no / Serial no (as mentioned in your INVOICE/BOX): 1) 2) Type of Equipment:(Handset/laptop/Phablet/Tablet) DETAILS OF LOSS Please enter relevant information according to the nature of your claim i.e. (Theft/Burglary/ Damage) H M M DD/MM/YYYY Time of loss: H *Date of Loss/Damage: *Type of loss: Theft *Brief description of incident of loss: Is there any other insurance cover for this equipment, if yes then please provide entire detail: (If the space is insufficient use a separate sheet & attach) *Estimate of loss: INR: Provide Intimation number, if reported through web or call: *To be filled in case of Theft claims *Police Station, where the matter have been reported: *Police Reference No: *10 digit Mobile number used at the time of loss: (*Applicable only for Mobile Handset) Type of SIM tariff (Prepaid/ Postpaid connection): (*Applicable only for Mobile Handset) Letter for barring SIM services given to Network Provider (YES/NO): (*Applicable only for Mobile Handset) *SIM Network Service If YES Please give date of submission: DD/MM/YYYY Declaration I/We agree to provide additional information to the company, if required. I/We the above mentioned, do hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing statement in every respect & if I/We have made, or in any further declaration the company may require in respect of the said loss, shall make any false or fraudulent statement, or any suppression or concealment, the policy shall be void and all rights to recover there under in respect of reimbursement shall be forfeited. Date: Place: Signature of Insured Person/Beneficiary Attach a copy of Photo ID - cum - signature proof Declaration Form – Theft Claim Date: …...... /...…….. / 20… From, Mr. / Ms. (Claimant Name) Address Line 1: Address Line 2: City/District: Street Name: Pin code: State: To, The New India Assurance Co. Ltd 87, M. G. Road, Fort, Mumbai – 400001 I/We Mr. / Ms. ………………………………………………………….would hereby like to inform that I/We had purchased the insured equipment from M/s. NSI Infinium Global Limited, vide Invoice No……..…………..………………………… Dated……/……/20….. Type of Equipment: *Bearing IMEI No.1) *Bearing IMEI No.2) Make & Model No. as and the said equipment have been lost/damaged on dated ….……/….……/20……., detailed description of loss/damage is as mentioned below. Detail Description of Incidence of loss/damage: ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- In connection to the aforementioned loss, I would hereby like to assign, transfer my authority to The New India Assurance Co. Ltd, 87, M.G. Road, Fort, Mumbai – 400001 for the said equipment. I/We agree to submit the salvage in case the claim is approved for total loss. I/W e have read all the above mentioned information and I accept the same in totality and the same are true to the best of my/our knowledge. I/W e hereby abide the terms and conditions of the policy. Thanking you, Name & Signature of the Claimant/Insured: Date: ………/……….. / 20…… To, Customer Service Manager, …………………………………………. …………………………………………. …………………………………………. Reg.: Barring SIM Services of Mobile No: (*Applicable only for Mobile handsets/Tablet/Phablet with SIM) Dear Sir/Madam, This is to inform you that Mobile No:_________________________________________________ is in the name of ___________________________________________________________________& address registered with you is__________________________________________________________________________________________ & I/We was using the (prepaid/postpaid SIM connection)_____________________________________________. I/We would hereby like to inform you that my mobile along with the SIM for the no________________________ have been lost / stolen on ………/………/201….. Accordingly I / we would hereby request you to kindly bar the incoming and outgoing calls & all related services for the said number. Please do the needful and bar the calls on receipt of the said letter. I / we would further request you to kindly let us know your reference no. for aforementioned request along with new SIM no. Your Ref. No.:________________________________ New SIM no.: ___________________________________________________________ (Mentioned on the backside of the New SIM package issued) Thanking you, Signature & Address of Claimant/SIM Owner Seal & Signature of Service Provider Date: Place: Date: Place: Authorized Signatory Name of SIM Service Provider:________________________ To, Police Station In charge ------------------------------------------------------------------------------------------- Date: Reg.: Lodging a complaint against equipment bearing IMEI/Serial No.___________________ Dear Sir, I/We Mr. / Ms. ………………………………………………………….would hereby like to inform that I/We had purchased insured equipment from M/s. NSI Infinium Global Limited, vide Invoice No……..…………..………………………… Dated……/……/20….. *Bearing IMEI.No.1/Serial No. ……………………….. *Bearing IMEI No............................................. Make & Model No. ………………………………………………… Type of Equipment: (Handset/laptop/Phablet/Tablet) . The said equipment has been stolen/lost on date ….……/….……/20……., detailed description of loss is as mentioned below. Detail Description of Incident: I / we was/ were using the service of (Mobile Service Provider name) and my 10 digit mobile no. was ___________________________________________ I/we have already informed the service provider to bar all the SIM services (including incoming & outgoing calls) against the aforementioned no. letter in effect of same is attached herewith for your ready reference. I / We would hereby like to lodge a complaint for the stolen mobile and request you to kindly assist us in finding the said mobile. As soon as the said mobile is recovered kindly inform to me/us. I /We would further request you to kindly let me/us know the reference no. (General diary/Daily diary number) ________________________________________ for our complaint; so that same can be used in future correspondence. Thanking you Signature of the claimant/Insured Place: Seal & Signature of Police Station Place: Claim Document Checklist – (For Theft Claims) Want to know about Claim Document Checklist – It's pretty hard to remember what to do after the initial shock and surprise after losing your Equipment If you are involved in such an incident, a checklist is to help ease your mind if you are involved in a loss, follow these tips to make sure you are prepared. Please note all the following documents need to be submitted to initiate the claim procedure with insurance company & we “UIBSPL” service provider will assist you to put forward all your claim documents. 1) Claim Form. 2) Declaration Form. 3) Call Barring Certificate 4) Police Complaint Copy 5) Original Purchase Invoice 6) A copy of Claimant and SIM owner, photo cum Signature ID proof. 7) In case of claimant is other than purchaser, relationship proof between claimant & purchaser. 8) If the equipment is purchased by Company, a letter on companies’ letter head confirming authorized person/user. These documents can also be downloaded from webpage http://iphoneinsurance.euniversal.co.in Note: Unless requested, do not send your Mobile accessories like Battery, Earphone, charger, Data cable, Mobile Box etc. If lost or misuse, we do not undertake any responsibility. Kindly fill all the details in true & correct manner with regards to your claim for hassle free claim experience and process. Submit the required original documents within 15 days from the date of registration of your claim. Please note that your claim documents will be forwarded by our team only when it is complete in all manners as required by Insurance Company All original claim documents will be retained by Insurance Company & hence it is advisable to maintain a copy for your record. For any assistance do call us on 022 4910 7910 or send an SMS as UIBSUPPORT (Space) IPHONEINSURANCE (Space) <your 10 digit mobile number> e.g. UIBSUPPORT ) IPHONEINSURANCE 1234567890 or write us at [email protected] and we shall be more than happy to assist you. ___________________________________________________________________________________ Version– 2.1 All rights reserved ©Universal Insurance Brokers Services Pvt. Ltd. Section 1 - Definitions This document gives information about Insurer, Insured, Beneficiary/User and Insured Equipment etc & other terms & conditions Proposer: Apple Certified Distributors/Partners for the benefit of their end consumer/beneficiary, whereby customer purchase an Insured Equipment during the Policy Period, through their Medium Insurer: The New India Assurance Company Limited Issuing Office: DO no - 111700, 3rd Floor, Asian Building, R. Kamani Road, Ballard Estate, Mumbai – 400001 Beneficiary/User - Purchaser of the new equipment bundled along with insurance. However his / her Spouse, Children & Parents can use the equipment. Where the purchaser is a company, beneficiary/user shall mean any representative/ employee of the company authorised to use the Equipment Insured Equipment: Insured Model as shown on purchase Invoice restricted only to Apple products such as I Phone/ I Pads or Laptops Medium: B2B Partner/ offline & online retailer of proposer only for Apple products Administrator/Facilitator/Coordinator: Universal Insurance Brokers Services Private Limited (UIB) & its ancillary partner’s if any Cover Period: 12 month from the date of 1st purchase of Insured Equipment by beneficiary. Sum Insured: Declared value by Proposer / MRP or Invoice Value whichever is lower. Policy Period: 23rd March 2015 to 22nd March 2016. Section 2 – The scope of cover Provided beneficiary/user has purchased Insured Equipment and same is mentioned in the invoice issued by Proposer medium to end customer i.e. beneficiary/user and proposer have declared Insured Equipment to insurer and paid appropriate premium. Insurer in the following event to Insured Equipment will accept liability towards repair or replacement with same or similar equipment or at their option will arrange for payment as per policy terms and condition, if equipment Suffers accidental physical damage to the Insured Equipment and/or such damage cause’s equipment to stop working. Fails to work because accidentally fluid has entered its internal circuitry, resulting into stoppage of the insured equipment. Burglary including theft and housebreaking Stolen from a locked building/room/vehicle. Fire, lightening and explosion. Act of god perils Damage or theft during riot, strike & malicious damage. Beneficiary will not be eligible for any compensation, for any loss or damage to accessories even if forming a part of standard pack or to any complimentary or ancillary product/s, made available. Section 3 – Exclusions This Insurance policy does not cover: 1. Loss, such as lost, forgotten/misplaced/left unattended, missing, fallen and any loss under mysterious circumstances. 2. Loss resulting from or caused by theft, or attempted theft of insured equipment, left in unattended vehicle or room except car of fully enclosed saloon type or room, having at the time all the doors/windows and other opening securely locked and properly fastened. 3. Loss due to intentional act or wilful neglect. 4. Loss arising after 12 month from date of purchase. 5. Any loss due to hire or loan of the insured equipment to a third party or if ownership is transferred. 6. Loss arising due to unlawful act including Terrorist activity, War, Nuclear Explosion, Radioactive Contamination, Chemical, Biochemical, Biological, Electromagnetic, Cyber Attack etc. 7. Any loss if the insured equipment is not connected to any cellular network of service provider. 8. Consequential loss of any kind or description including wear & tear, manufacturing defects etc. 9. Loss caused by incorrect storage, poor care and maintenance, careless use, gross negligence, incorrect installation and incorrect set-up. 10. Loss covered by supplier, dealer or factory warranty. 11. Any loss of data or software installed in the equipment. 12. Any loss arising outside the territorial limits of India. 13. Any loss which is cosmetic in nature and does not result in to complete stoppage of/or functioning of equipment. 14. Any loss which is due to regular wear and tear and does not result in to complete stoppage of/or functioning of equipment and loss effecting to SIM card and/or any ancillary product etc even if the equipment result into complete stoppage of working. 15. Any loss prior to delivery of insured equipment, if purchased online. Section 4 – Compensation Total Loss: – Compensation for any total loss claims will be by way of NEFT or payment to the beneficiary account by suitable mode. Maximum liability per Insured Equipment shall be Sum Insured, subject to excess and depreciation depending on age of insured equipment from date of purchase at the date & time of loss. Partial Loss: – Compensation for any Partial Loss claims will be by way of repair or exchange as per OEM policy to the insured equipment and reimbursement by way of NEFT/payment to the beneficiary account by suitable mode. Maximum liability shall be cost of repair or exchange cost, subject to excess. If the repair or exchange cost or maximum liability at the time of loss exceeds the total loss settlement, insurer shall settle the claim on total loss under BER (Beyond Economic Repair). PTO... If the repair value is more than the compensation payable, beneficiary has to bear the difference between repair value and approved amount. Excess is minimum value which shall be deducted in each and every claim. Excess is 5% of the claim value, or 300 rupees, whichever is higher. The Sum Insured or maximum liability shall be calculated as follows by applying depreciation on the claim value only for total loss: Age 0 to 90days 91 to 180 days More than 180days Depreciation 10% of Purchase Price/SUM INSURED 20% of Purchase Price/SUM INSURED 50% of Purchase Price/SUM INSURED Maximum of 2 claims shall be addressed by the Insurer, during policy period; subject to maximum liability or Sum Insured at the time of loss. Section 5 – Policy Condition User or beneficiary agrees that: Take all reasonable steps to safeguard the insured equipment. In the event of loss, declare/disclose all the material fact about the incidence or event and submit salvage. In the event of a loss, all benefits shall be forfeited, where there are any misrepresentations, misdescripition or non disclosure of any material fact significant to admission of liability and assessment of loss. Section 6 – Claim Procedure In the event of loss insured or beneficiary is required to do following steps: An immediate intimation (not later than 48 hours from the date and time of loss) about loss should be given to insurer or Universal Insurance Brokers (UIB) on 022 – 4910 7910. All claim related documents or correspondence need to be submitted to UIB and all such documents or correspondence should reach UIB not later than 15 calendar days from the date and time of the event of loss. Theft Category – The event should be immediately (not later than 48 hours from the date and time of loss) reported to the nearest police authorities and police acknowledgment/receipt to be furnished. The event will have to be simultaneously notified to the cellular network service provider not later than 48 hours from the date and time of loss and a written acknowledgment on confirmation of barring of SIM services from network service provider to be furnished. Damage Category – The event needs to be notified to UIB with proximate cause or reason of loss & obtain service estimate towards damage. Do not get the damaged insured equipment repaired unless intimated over helpline of UIB & further authorized by insurer. Section 7 – Contact points for Claims All claim related queries and submission of claim document/s or correspondence should be directed to Universal Insurance Brokers Services Private Limited by calling on 022 – 4910 7910 or by sending an SMS as “UIBSUPPORT (space) IPHONEINSURANCE (space) <mobile number> (on which customer wish to get reply from UIB) to 56767 E.g. UIBSUPPORT IPHONEINSURANCE 1234567890 All claim related documents or correspondence need to be submitted by the user/beneficiary to Universal Insurance Brokers Services Pvt. Ltd (UIB) in Duplicate i.e. Original claim document/s with one additional photo copy of all original claim document/s. Note: Original Documents shall be retained by Insurer at the time of claim and shall not be returned to the insured/claimant. For claim guidance or assistance or claim related queries or information related to policy, beneficiary can contact Insurer/UIB. Insured/Beneficiary can inform about the claim i.e. claim intimation, know their claim status and also get all other relevant information by calling on 022 – 4910 7910 or writing an email at [email protected] or by sending an SMS as “UIBSUPPORT (space) IPHONEINSURANCE (space) <mobile number> (on which customer wish to get reply from UIB) on 56767 E.g. UIBSUPPORT IPHONEINSURANCE 1234567890 or log on http://iphoneinsurance.euniversal.co.in The Insured may refer http://iphoneinsurance.euniversal.co.in to view or download for all insurance claims related documents. This insurance policy is valid only if make and model of the insured equipment is Apple Insurance is subject matter of solicitation.
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